The number of patients with end-stage kidney disease (ESKD) requiring maintenance dialysis is increasing rapidly in the U.S. ESKD is typically accompanied by multiple co-morbidities, including other organ failure. Complications are common, and they undermine survival and quality of life. When acute illnesses are superimposed on co-morbidities, they typically cause death. Few escape acute life-threatening episodes; yet little is known about the trajectories of symptoms, physical functioning, psychosocial needs, and emotional and spiritual well-being of patients with ESKD when they experience acute life-threatening episodes. Such data are in great need to guide palliative care for this population. This proposed study will therefore identify trajectories of symptoms, physical functioning, psychosocial needs, and emotional and spiritual well-being in a sample of 200 patients with ESKD who are at a high risk of experiencing acute life-threatening events and mortality within 12 months. Specific aims are to (1) identify longitudinal patterns of the five dimensions of quality of life, i.e., symptoms, physical functioning, psychosocial needs, and emotional and spiritual well- being of patients with ESKD who experience acute life-threatening events; (2) examine the relationships among these five dimensions of quality of life over time and the impact of acute life-threatening events on the relationships; and (3) examine the relationships of trajectories of the five dimensions to survival. This study will use a prospective descriptive design with repeated measures over 12 months, or until patient death. The five dimensions of quality of life will be assessed monthly. A linear mixed model will be used as the primary statistical technique for assessing the longitudinal patterns of the five dimensions of quality of life and the relationships among the repeated measures and multiple predictors of each dimension. This study will provide data to help identify and meet the complex needs of patients with ESKD who experience acute life-threatening events superimposed on the demands of dialysis and co-morbidities.